PATIENT SAFETY CULTURE AND PATIENT SAFETY … · 2 Patient Safety Culture and Patient Safety...
Transcript of PATIENT SAFETY CULTURE AND PATIENT SAFETY … · 2 Patient Safety Culture and Patient Safety...
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PATIENT SAFETY CULTURE AND PATIENT SAFETY IMPLEMENTATION
IN STELLA MARIS HOSPITAL DURING NATIONAL HEALTH INSURANCE ERA
By :
Fridawaty Rivai
PUBLIC HEALTH
HASANUDDIN UNIVERSITY
2017
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Patient Safety Culture and Patient Safety Implementation
in Stella Maris Hospital during National Health Insurance Era
Fridawaty Rivai1, Ima Fatimah
1 , Khalid Saleh
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1Hospital Administration Department, Faculty of Public Health,
Hasanuddin University
(email: [email protected])
(email: [email protected])
2Central Public Hospital of Dr. Wahidin Sudirohusodo Makassar
(email: [email protected])
Correspondence Address:
Fridawaty Rivai Hospital Administration Department
Faculty of Public Health
Hasanuddin University Makassar
Telp: +6281355250628
Email: [email protected]
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ABSTRACT
Implementation of patient safety in hospital is influenced by several factors such as culture
of patient safety. The aim of the research was to analyze the effect of patient safety culture
on the implementation of patient safety in Stella Maris Hospital in 2016. The research was a
quantitative studyusinganalytic operationaldesign withcross-sectional approach. The
samples consisted of 234people selected using proportional stratified random sampling
technique. The results of the research indicate that there are variables of patient safety
culture which does not affect the implementation of patient safety. The variables which do not
have effect in intensive care unit are supervisor’s expectation and action to promote patient
safety (p=0.819). Emergency units which do not have effect are organizational learning and
continual improvement (p=0.469). Inpatient installations which do not have effect are
staffing (p=0.778) and outpatient installation nonpunitive response of error (p=0.511).
Surgery room which does not have effect is unit teamwork (p=0.839). Pharmacy installation
which does not have effect is staffing (p=0.656). Laboratory installations which do not have
effect are organizational learning and continual improvement (p=0.829). Radiology
installation which does not have effect is management support on patient safety (p=0.133),
while the variables which do not have effect in hemodialysis are organizational learning and
continual improvement (p=0.443).
Keywords : patient safety culture, patient safety implementation
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INTRODUCTION
The Government of the Republic of Indonesia in January 2014 perform a transformation of
the health system in Indonesia to begin convening of the National Health Insurance program
(JKN). The National Health Insurance is a government program that is contained in the program
of the program National Social Security System (SJSN) and it is an implementation of Universal
Health Coverage. National Health Insurance (JKN) program aims to guarantee health care
benefits and financial protection benefits for its participans.
Implementation of National Health Insurance (JKN) program organized by Social Security
Agency (BPJS) require cooperating with various health facilitie, one of which is the hospital.
Hopital in cooperation with Social Security Agency must meet the quality standard or hospital
accreditation standard. Therefore, health services to participans JKN need to focus on service
quality, patient safety oriented, effectiveness of action, and based on patient needs (President
Decree Number 12 in 2013).
Implementation of National Health Insurance (JKN) program by Social Security Agency
(BPJS) in hospital bring concequences both from the aspect of financing and quality of care.
The existing system requires health workers in hospitals in order to improve efficiency in
service. Several studies have shown that dissatisfaction occurs in a hospital doctor who
implement JKN (Meutiah and Ishak, 2015).
Patient safety in the hospital became a serious global issue. Since the launch of patient
safety programs by WHO in 2004, currently around 140 countries struggle with the challenge
of unsafe services (WHO, 2014). Emerging and developing patient safety along with the
increasing number of patient safety incidents. Patient safety and focus efforts on reducing the
number of patient safety incidents are preventable (Raleigh, 2009). Figures patient safety
incidents reported by various negara.Tahun 2006 study conducted by the World Health
Organization (WHO), Eastern Mediterranean and African Regions (EMRO and AFRO), and
the WHO Patient Safety in 8 developing countries. The result keselamatanpasien incident
occurred in 2.5% -18.4% of the 15 548 medical records at 26 hospitals, 83% were
preventable, 30% were related to patient deaths and 34% related to therapeutic errors in
clinical situations were relatively complex. In addition, WHO also reported on a study of 58
hospitals in Argentina, Colombia, Costa Rica, Mexico and Peru by IBEAS (The Latin
American Study of Adverse Events) and involving 11 379 inpatients. The result is a 10%
admission experienced patient safety incidents caused by the service kesehatan.Insiden
patient safety.
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Patient Safety Organization (PSO) in 2014 reported more than 27,000 events from 110
health organizations in California, USA, 94% or 25,380 were incidents of patient accidents.
Occurrence of accidents due to harm in patients by 27% or 6,852. Severe accident incidence
or death of 1.2% or 304. While the incidence of almost injury and unsafe conditions
amounted to 6% (1620).
Incidence of the above are also found in Indonesia. In 2007, The Hospital Patient
Safety Committee (KKPRS) reported patient safety incidents as many 145 incidents. Other
data regarding patient safety incidents in Indonesia showed that near miss (KNC) more
reported than adverse event (KTD).
One of the hospitals has a high patient safety incident rate in the city of Makassar was
Stella Maris Hospital. The number of patient safety incidents incidents that is patients fell as
much as 2 cases, 3 cases, 5 cases, and 1 case. Dispensing errors by as much as 5 cases, 9
cases, and 8 cases. Nosocomial infections as much as 1.5%, 8.4%, 6.9% and 5.6%. The
incident happened in the range of years 2012-2015.
Patient safety incidents can be reduced or prevented what happened by knowing the
factors that contribute to patient safety incidence. It has previously been presented that patient
safety program is a program that is working to reduce and prevent the patient safety incidents.
In addition to being influenced by the implementation of patient safety program, patient
safety incidents can also be influenced by several factors. WHO (2009), in the Human
Factors in Patient Safety: a Review of Topics and Tools bring up several factors that affect
patient safety incidents. WHO developed the four categories of strongly factors relate to the
cause of patient safety incidents, namely individual factors, team work factors, organization
and management factors and environmental factors. Henriksen (2008) also explains that
patient safety incidents is influenced by factors such as the individual's abilities, experience,
work fatigue. Factors such as the complexity of the work nature of the treatment, the flow of
work, interruptions. Physical environmental factors include lighting, temperature.
Management factors such as cultural safety, employee development, leadership. In addition,
external factors such as technological development organizations, policy related government
health services was also mentioned as a factor that could affect patient safety incidents.
Implementation of patient safety programs more effective compared to other factors in
reducing the incidence rate of patient safety.
In The Patient Safety Handbook, Behal (2004) explains that the successful
implementation of patient safety program by staff at the hospital can be affected by several
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components. One such component is a culture of patient safety. Research Nygren et al
(2013), indicates that the patient safety culture be a contributing factor in improving patient
safety. Patient safety culture would encourage reporting of incidents and eliminate the habit
blame when patient safety incident. A similar study conducted by Coughan (2013), the
research results show that a key component of patient safety culture that is leadership,
collaboration, and learning from mistakes contributes greatly to patient safety.
Patient Safety Goals consists of six goals, the accuracy of patient identification,
increase effective communication, improving the safety of drugs that need to watch (high
alert), the certainty of the right location, proper procedures, and appropriate patients for
surgery, the reduction of risk of infection related to health care, and reduction the risk of
falling.
Based on data from patient safety incidents in Stella Maris Hospital and the research
that has been described above, the researcher interested in conducting research to analyze the
patient safety culture and implementation of patient safety goals (IPSG) at the Stella Maris
Hospital in National Health Insurance (JKN) Era.
MATERIALS AND METHODS
The research was conducted at the Stella Maris Hospital Makassar. The study was
observational analytic research with cross sectional design. The study population was the
hospital staff in the installation service. Sampling technique with proportional stratified
random sampling technique with a sample size of 234 respondent.
Data collected in the study are primary data and secondary data. Primary data taken
through questionnaires, while secondary data or supporting data obtained from the relevant
sections. Descriptive data analysis, aims to describe the characteristics of the sample and are
presented in the form of a frequency distribution. Bivariate analysis, to see the relationship
between the independent variable on the dependent variable. While the multivariate analyzes
were performed to obtain information about the influence of the independent variables
together of several independent variables on dependent variables. Presentation of data in
tabular form and accompanied by narration.
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RESULT
1. Characteristics of Respondents
Table 1. Distribution Characteristics of Respondents Research at Stella Maris
Hospital Makassar, in 2016
Characteristics of Respondents Frequency Percent (%)
Age (years)
17-25 52 22.2
26-35 137 58.5
36-45 38 16.2
46-55 7 3.0
Total 234 100
Gender
Man 72 30.8
Woman 162 69.2
Total 234 100
Level of education
High school 17 7.3
D3 Equal 113 48.3
S1 102 43.6
S2 2 0.9
Total 234 100
Profession Respondents
Doctor 11 4.7
Nurse 177 75.6
Pharmacist 22 9.4
Laboratory assistant 14 6.0
Radiographers 10 4.3
Total 234 100
Table 1 shows the characteristics of the respondents were dominated by 26-35 year age
group and mostly female. D3 education level is equal to the profession most were nurses.
2. The Influence of The Independent and Dependent Variables
The results of the bivariate analysis between the variables of organizational culture
that consists of 12 dimensions with variable implementation of patient safety show that
of the 12 dimensions of patient safety culture, there are only 4 dimensions related to the
implementation of patient safety. The results can be seen in the following table:
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Table 2. Results of Analysis Relationship Between the Dimensions of Patient Safety
with the Implementation of Patient Safety in Stella Maris Hospital
Makassar, in 2016
Independent Variables
(Patient Safety Culture)
Patient Safety Implementation
r p
Supervisor/Manager Expectations & Actions
Promoting Safety
0.051 0.440
Organizational Learning—Continuous
Improvement
0.176 0.007
Teamwork Within Unit 0.145 0.027
Communication Openness -.040 0.539
Feedback and Communication About Error 0.108 0.101
Nonpunitive Response to Error 0.146 0.025
Staffing -.040 0.542
Hospital Management Support for Patient Safety 0.124 0.059
Teamwork Across Hospital Units -.034 0.604
Hospital Handoffs and Transitions 0.076 0.247
Overall Perceptions of Safety -.004 0.956
Frequency of Event Reporting 0.160 0.014
Table 2 shows that the cultural dimensions of patient safety is an ongoing
organizational learning and continuous improvement had a significant association with
the implementation of the safety of the patients (p = 0.007). Dimensional teamwork
within unit also has a significant relationship with the implementation of patient safety
with p = 0.027. Two other dimensions which will nonpunitive response error and
frequency of event reporting also had a significant association with the implementation
of patient safety with a p-value of each ie, p = 0.025 and p = 0.014. While eight other
dimensions do not have a significant relationship with the implementation of patient
safety.
Then performed multivariate analysis to determine the dimensions of patient
safety culture that has the greatest affect to implementation of patient safety. The results
can be seen in the following table:
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Table 3. Multivariate Analysis of the Dimensions of Patient Safety and the
Implementation of Patient Safety in Stella Maris Hospital Makassar, in
2016
Dimensions of Patient Safety Culture Exp (B)
Organizational Learning—Continuous Improvement 1.583
Teamwork Within Unit 1.413
Nonpunitive Response to Error 1.229
Frequency of Event Reporting 1.397
Table 3 shows that of the four dimensions of patient safety culture relating to the
implementation of the patient safety, then the most influential dimensions are
organizational learning and continuous improvement with Exp (B) $ 1,583 and the
lowest is non-punitive response to error.
DISCUSSION
This study showed that there are only four dimensions of patient safety culture
implementation affecting the safety of patients, while eight other variables have no effect.
The dimensions of patient safety culture that influence the organizational learning and
continuous improvement, teamwork within unit, response nonpunitive to error and frequency
of event reporting.
1) The Influence Dimensions of Organizational Learning and Continuous
Improvement to Implementation of Patient Safety
Garvin (2000) defines organizational learning as a membership organization to create,
acquire, interpret, transfer and sharing of knowledge, which is aimed at modifying its
behavior to describe the knowledge and insights. Another notion mentioned that the learning
organization is an opportunity given to employees so that the organization becomes more
efficient (Luthans, 1995). Organizational learning is based on the basic principles of learning
that receive and gather information, interpret it, and act upon the interpretation of such
information (Garvin, 2000). Learning organization presents the principles and the foundations
that enable organizations to learn. Organizational learning can also be described as a set of
organizational behavior that demonstrates a commitment to learning and continuous
improvement.
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Organizational learning and continuous improvement is willingness of health workers
to learn and perform the activities regarding patient safety such as socializing, discussions,
and evaluating patient safety procedures. Organizational learning and continuous
improvement also means that mistakes or errors that occur in hospitals becomes the origin in
the positive changes made by the hospital, the change will be evaluated in order to know how
effective in resolving issues related to patient safety incidents (AHRQ, 2004).
Organizational learning and continuous improvement in patient safety errors made in an
effort to become better. Seen on the dimensions of organizational learning in the form of
activeness in improving patient safety, always make a mistake to change for the better and the
desire to do the evaluation of the error. Implementation of organizational learning and
continuous improvement is considered to be good at Stella Maris Hospital. Especially in the
dissemination of patient safety. Each officer must get the socialization, than that every new
employee must obtain dissemination of patient safety. In this case it can be said that
organizational learning has a major role in shaping the organizational culture, especially the
culture of patient safety. Research on organizational learning is done by Maktabi & Khazaei
(2014), which indicates that organizational learning has a positive influence on the
organization's ability to innovate and the performance of the organization itself. In addition a
similar study also conducted by Nafei (2015), the research results show the direct influence
of organizational learning on organizational performance. So it is advisable for organizations
to pay more attention to organizational learning. research results show a direct effect of
organizational learning on organizational performance. So it is advisable for organizations to
pay more attention to organizational learning. research results show a direct effect of
organizational learning on organizational performance. So it is advisable for organizations to
pay more attention to organizational learning.
2. The Influence Dimension of Teamwork Within Unit to Implementation of Patient
Safety
Teamwork within unit is mutual help, support, respect, and reminiscent in carrying out
the work by the individual in the work unit to implement patient safety programs in order to
avoid patient safety incidents. Teamwork within unit at the Stella Maris Hospital has been
running well. In installations of the research found that the officers would be willing to assist
other officers in the installation if you have a tough job. Besides the clerk did not hesitate to
remind the other officers to carry out the service process in accordance with the applicable
SPO. So that every officer will carry out services that support patient safety.
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Teamwork within unit is required in the implementation of patient safety. The safety
culture is high because of the good cooperation in the patient's safety unit. According to
Baker et al., (2005) team work is needed by officers to improve patient safety through mutual
error. Cooperation in the unit is also related to communication between officers in the unit.
For example on pharmaceutical installations, communication between physicians and
pharmacists is very important. Physician and pharmacist work is actually complementary
(complementary), hypothetically it can be said that the cooperation can have a positive effect
on patient outcome (outcome of patient). A collaboration between physicians and pharmacists
includes, for example, tracing a complete and accurate history of drug information,
prescription-based prescriptions; Early detection of prescription drugs, increasing cost-
effectiveness in prescribing drugs, increasing knowledge and skills of each side for patient
satisfaction. Unoptimal collaboration can benefit patients. Oral drug delivery is not adjusted
to the pharmacokinetic properties of drugs that can lead to decreased drugs.
Patient safety is a team effort, the most effective teams have the same goal in work, and
their teamwork is not efektif creating various opportunities for errors (Merry & Brown, 2002;
White, 2004). Research conducted by Sorbero et. al., (2008) showed that good cooperation in
the ICU will affect the lower mortality and length of stay of patients in the ICU. Studies show
that 70% of medical errors can be reduced through the interaction between the teams at the
plant hospital. Patient safety experts agree that communication and cooperation factor in
other units such as mutual support and help to prevent and reduce medical errors. The Joint
Commission International (2011) underlines that it is important to promote cooperation in the
unit behavior and improve communication among officers that are useful to prevent the
occurrence of errors.
3. The Influences Dimension of Response Non-punitive to Error to the
Implementation of Patient Safety
Response non-punitive to errors was the attitude of not blaming individuals when
conducting and reporting the incident for the improvement of patient safety program.
Characteristics of reporting the incident to the hospital patient safety team has several
characteristics. The characteristics that are not punish or blame, confidential, independent,
expert anaysis, timely, orientation systems, and responsive. The first characteristic is to be
not punish or blame, which means that the complainant free of fear and retaliation or
punishment as a result of the report. It is important to note, because since there are many
hospitals that culture is not to blame in case of error and reported it has not gone well.
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In this era where patient safety became mandatory in hospitals, blaming culture should
be transformed into a just culture. Just culture is a condition where the staff at the hospital is
open and motivated to provide information on what can or can not be accepted, their fear
when the staff report error events, the cooperation between the members of the staff. Wachter
and Pronovost in the New England Journal of Medicine even called no-blame approach as the
easiest tool to improve patient safety by reducing error at the hospital. However Khatri et al.,
(2009) actually found that the hospital is still difficult to move from just blame culture to
culture.
Atmosphere working environment still blame culture can reduce working motivation of
health workers. They tend to be lazy to innovate in doing its job, because they think if done
wrong will have a negative impact on him. Especially if the blame cultureini stressful job.
Officers feel pressured in their duties.
Stress is a state of a person under stress conditions due to the conditions that affect it,
such conditions can be obtained from within oneself and the environment outside of oneself.
Stress can cause a negative effect on psychological and biological situation for employees.
According to Robbins (2002) stress is a dynamic condition in which an individual is faced
with opportunities, limitations or demands in accordance with the expectations of the results
that he wants to accomplish in critical condition and erratic. Gitosudarmo and Suditta (1997),
that stress has positive and negative effects. The positive impact of stress at a low level to a
moderate level functional in the sense of acting as drivers of employee performance
improvement. Research conducted by Khasawneh & Futa (2013) showed that work stress
caused by environmental organizations can affect the performance of the individual hospital.
From this study it can be concluded that the blame culture can broadly affect the performance
of health workers in hospitals.
4) The Influence Dimensions of Frequency of Event Reporting to Implementation of
Patient Safety
Patient safety system generally consists of several components such as incident
reporting system, analysis of learning and research of incidents arising, development and
implementation of solutions to pressing errors and adverse event (KTD), and the
determination of a variety of patient safety standards based on knowledge and research.
Errorberkaitan event reporting with the evaluation of the safety of the patient. If considered
patient safety programs have not been effective in reducing or eliminating the error it is
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necessary to repair and development of patient safety programs. Patient safety event reporting
is actually a form of support for the implementation of patient safety itself.
Incident reporting is a system for documenting patient safety incident reporting,
analysis, and solutions for learning. Incident reporting system is done internally in the
hospital and external to the Hospital Patient Safety Committee (KKP-RS). Internal patient
safety incident report is reporting in writing any potential condition of injuries and incidents
that happened to the patient, family visitors, and employees that occur in hospitals. External
patient safety incident report KKP-RS. Reporting anonymously and in writing to KKP-RS
every potential condition of injuries and patient safety incident that occurs in patients and has
analyzed the cause of, and solution recommendations. Incident reporting aims to reduce the
incidence and correcting the system in order to improve patient safety. Each incident must be
reported internally to TKPRS later than 2 × 24 hours according to the report format. TKPRS
do the analysis and provide recommendations and solutions on reported incidents and report
the results of their activities to the head of the hospital.
The hospital shall develop incident reporting system. Moreover Hospital Patient Safety
Committee (KKP-RS) has established guidelines for reporting of patient safety incidents. One
of the seven steps to patient safety also is developing a reporting system. Even the output of
patient safety is a culture of reporting events that have occurred. But in reality the problem of
error in the health care system reflects the iceberg, because of the generally adverse events
detected were found by chance alone. Most of the others are likely not reported, not recorded,
or even escape our attention.
Iskandar (2014) found that the causes of the low reporting of patient safety incidents
due to the persistence of cultural blame when reporting the incident or made a mistake, lack
of knowledge about reporting the incident, the reluctance to report for lacking commitment
from management or related units, no reward from the hospital if the report and the lack of
activity in the hospital patient safety committee (KKP-RS).
The study by Gunawan (2015) also showed that the factors causing low report patient
safety incidents caused by fear on the head unit. Incident reporting and komitmenyang
require high involvement of organizations and individual caregivers (The Health Foundation,
2011). Not only officers as service providers but also of the hospital management. Caregivers
should be open in reporting the incident, the hospital management to provide workflow and
reporting guidelines, forming a team of hospital patient safety (TKP-RS). Especially develop
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no blame when reporting and making mistakes. Regulation of Health Minister Number 1691
in 2011 on the Patient Safety Hospital one of which is communication.
CONCLUSIONS
There were four dimensions of patient safety that affect the implementation of patient
safety. The demands of quality services, especially in the era of national health insurance is
reached target expects quality control and cost control have not been fully achieved.
Dimensional teamwork within unit is the most influential dimension pelaksaaan patient
safety.
Stella Maris Hospital expected to further improve patient safety culture, as some
variables of patient safety culture at the plant is still relatively moderate category. Besides
implementing a no blame culture so that the workers are not afraid in reporting the incident
and develop training programs on patient safety to health workers. With the enactment of
JKN the demands of effectiveness and efficiency increase hospital services should be
achieved, one of them by improving safety culture and implementation pasiem safery patient
in the hospital.
REFFERENCE
Behal R. (2004). An Organization Development Framework for Transformational Change in
Patient Safety: A Guide for Senior Hospital Leader. The Patient Safety Handbook,
36-51.
Daft R. (2008). Management. Jakarta: Four Salemba.
Eldeeb et al. (2016). Perceptions of Patient Safety Among Nurses at Teaching
Hospital.American Journal of Nursing Sciences, 5 (4): 122-128.
Dewi M. (2011). The affect received training weigh weigh patients on the implementation
and application of patient safety received by nurses at Husada Hospital, Jakarta. UI
Nursing Journal, 2 (2).
Gittel J. (2009). Relational Coordination: Guidelines for Theory, Measurementand Analysis.
Waltham: Brandeis University
Gunawan. (2015). Low Analysis of Patient Safety Incident Report in Hospital. Brawijaya
Medical Journal, 28 (2).
Alexander H. (2014). Causes Decrease Patient Safety Incident Reporting Brawijaya
Sakit.Jurnal Medicine, 28 (1).
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Khasawneh A. & Futa S. (2013). The Relationship Between Nurses' Job Performance
Stressand in the Jordanian Hospital.Asian Journal of Business Management, 5 (2):
267-275.
Coughan D. & G. Kaufman (2013). The Effect of Organizational Culture on Patient Safety.
Journal of Nursing Standard, 50-56.
Maktabi S. & Khazaei A. (2014). The Impact of Organizational Learning on Organizational
Performance and Organizational Innovation. International Journal of Economy,
Management, and Social Sciences, 3 (10).
Marjani. (2015). Documentation influence Weigh Thank Methods Patients with Situation,
Background, Assessment, Recommendation (SBAR) to the Patient Safety Incidents
in Space Medical Surgical Panti Waluyo Surakarta. Journal of Nursing, 1 (1).
B. Marquis & Huston J. (2010). Nursing leadership and management theories have and
aplikasi.Jakarta: EGC.
Nafei A. (2015). Organizational Learning and Organizational Performance: A Correlation
Study in The Kingdom of Saudi Arabia. American International Journal of Social
Science, 4 (2).
Nygrenet al. (2013). Factors Influencing Patient Safety in Sweden: Perceptions of Patient
Safety Officers in The Country Councils.BMC Health Services Research, 52.
Parand etal. (2014). Organizational Support on Patient Safety in Hospital. Journal of Patient
Safety, 1 (1).
Regulation of Health Minister Number 1691. (2011). Patient Safety Hospital. Ministry of
Health of the Republic of Indonesia.
Raleigh. (2009). Patient Safety Indicators For England From Hospital Administrative Data:
Case-Controlanalysis And Comparison With US data. BMJ Journal, 337.
Setyorini. (2008). Health Care Complaints Handling influence on Patient Confidence in
Regional Public Hospital District. Bantul. Yogyarakarta Medical Journal, 4 (15).
Sorberroet al. (2008). Outcome Measures for Effective Teamwork in Inpatient Care. RAND
Corporation Journal, 2 (1).
WHO. (2009). Human Factors in Patient Safety: Review of Topics and Tools. Geneva: World
Health Organization.